Proven Pathways New Client Submission-Main One

Welcome to Proven Pathways!

Please fill out our confidential form so we can learn more about you. This will help us have a conversation with you about our practice and how we could address your needs. We will endeavor to return your contact within one business day.
How did you hear about our practice?
We offer both in person and Telehealth services to clients in Ohio. If you will be seeking Telehealth services while physically in a state other than Ohio, please list any and all states that may apply (excluding brief trips, vacations, etc.)
Please check your insurance and we can have a discussion with you about what to expect:

I am out of network, but would like to self-payAetnaMeritainCignaMedical MutualOhioHealthyDevoted HealthTricare (we are a certified out-of-network provider)
We accept most, but not all Medical Mutual plans. We will need to ask some additional questions to help you determine if we are in-network with your plan. First, was your Medical Mutual insurance plan purcased on the Marketplace, or provided by an employer?

Purchased on the MarketplaceProvided by the policy holder's employer
Marketplace plans

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We do not accept some Medical Mutual (HMO) plans offered on the Marketplace. Please check with your insurance provider to verify that we are in-network with your specific plan before completing this form. If we are not in-network, please select "I am out of network, but would like to self-pay" before continuing with the form.

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Is the policy holder of the Medical Mutual insurance plan an employee of the state of Ohio?

Yes, the policy holder is a state employeeNo, the policy holder works for a private company, a city municipality, county, or school district
State Employee Plans

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Unfortunately, we are very likely out-of-network with your plan. Employees of the State of Ohio have Medical Mutual insurance for medical coverage, but not behavioral health. If you are a state employee, you almost certainly have Optum insurance for behavioral health (not Medical Mutual). Please call your insurance carrier or HR department to confirm.

State employees can also verify this by calling the number on the back of their insurance card for Behavioral Health. If the number goes to Optum Insurance, we are not in-network.

If you would like to still recieve services from us, please change your answer to "I am out of network, but would like to like to self-pay."

*Optum is owned by UnitedHealthcare. If you decide to look for other providers who accept your insurance, consider adding UnitedHealthcare (UHC) to your search, as the majority of providers who are in-network with UHC are also in-network with Optum (even if they don't list it on their websites). This information is for your convenience, and may not be accurate in all circumstances.

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Good news! At this point, it appears we are likely an in-network provider. We always encourage prospective patients to confirm with their insurance company before starting treatment. We will also double-check your insurance card if you decide to upload a copy of it.

Please continue completing the form...
Please note the following self-pay fees, and select the option that works best for you:

Licensed Psychologist (45 min: $220; 60 min: $285)Licensed Clinical Therapist (45 min: $200; 60 min: $275)Pre-licensed Postdoctoral Fellow (45 min: $200, 60 min: $275)Open to recommendation based on my needs and availability
Do you have a Medicaid insurance plan or a dual-eligible Medicare/Medicaid plan OR do you plan to apply for one of these plans in the next 6 months?

YesNo
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please provide the best times to reach you today and tomorrow. If you're completing this form over the weekend, please list your availability for Monday and Tuesday.
What is your age? We typically see clients 18 years and older but depending on the case can see between ages 15-17 as well.
Please briefly describe the primary reasons you are seeking treatment:

In the past two weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying/obsessing
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

Have you in the past received any mental health diagnoses?
Have you been tested for, or received a diagnosis of, a neurodevelopmental disorder in the past (e.g., autism spectrum disorder, ADHD, learning disorder)?
In the past 6 months, I have participated in the following treatment for my mental health:

Therapy (outpatient)Psychiatric medication managementIntensive outpatient treatment (IOP)Partial hospitalization program or day program (PHP)Residential treatmentInpatient mental health treatmentOther
With the right kind of treatment, I think I could make progress with improving my mental health.

YesNo
Should be Empty:

Welcome to Proven Pathways!